Nevada Facility Network

NevadaFacility Network

Downloads

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 TitleDescription
English Mileage Reimbursement Form Mileage reimbursement form in English
English Mileage Reimbursement Instruction Letter Mileage reimbursement instruction letter in English
Spanish Mileage Reimbursement Form Mileage reimbursement form in Spanish
Spanish Mileage Reimbursement Instruction Letter Mileage reimbursement instruction letter in Spanish
Standing Order CancellationA form used to temporarily or permanently cancel Standing Orders. A cancellation form is required for Standing Orders that need to be canceled for a week or more
Standing Order CriteriaA brief summary of what is required to schedule Standing Orders
Physician’s Transportation Restriction FormA medical necessity form required to be completed by the member’s physician or a licensed medical professional for a higher level of service or other need such as an escort
Consent and Release of Liability FormA form that is required for hospital transfers to another facility (facility to facility only) when no adult escort is available for the member who is a minor
Nevada Member English BrochureGeneral Information provided for English speaking members
Nevada Member Spanish BrochureGeneral Information provided for Spanish speaking members
EDI Form (Medical Provider Electronic Data Interchange)A form completed by Medicaid providers that qualify to register for our Facility Services Website (FSW) to set up reservations online at https://facility.logisticare.com
LogistiCare Nevada Operations Contact Phone Numbers & InformationKey contact information for our Nevada management team including phone numbers and websites

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